Southern States Reconsider Long-Standing Opposition to Medicaid Expansion: A New Era of Healthcare Coverage?

The healthcare landscape in the United States has been undergoing significant changes in recent years, with one of the most notable developments being the reconsideration of Medicaid expansion in several Southern states. Medicaid, the government health insurance program for low-income and disabled individuals, has long been a contentious issue in these states due to political opposition. However, the tide seems to be shifting as public support for expansion grows, and powerful sectors of the healthcare industry, particularly hospitals, make their voices heard.

One individual who stands to benefit from this potential change is Jolene Dybas, a part-time customer service representative in Alabama. Dybas earns less than $15,000 a year, which is below the federal poverty level and too low for her to qualify for subsidized health insurance on the Obamacare marketplace. She also does not meet the program requirements for Medicaid in her home state, leaving her in a coverage gap and facing hundreds of dollars a month in out-of-pocket payments to manage multiple chronic health conditions.

“I feel like I’m living in a state that doesn’t care for me,” Dybas said, expressing her frustration with the current situation. Alabama is one of ten states that have refused to adopt the Affordable Care Act’s expansion of Medicaid.

However, lawmakers in Alabama and other Southern states are reevaluating their opposition to Medicaid expansion. In Georgia and Mississippi, Republican legislative leaders are considering expansion, which could make more than 600,000 low-income, uninsured people in these three states eligible for coverage, according to KFF data.

The political opposition to Medicaid expansion has softened in part due to North Carolina’s Republican-controlled legislature voting to expand the program in 2023. Over 346,000 residents of the Tar Heel State have gained coverage as a result. The momentum from North Carolina has encouraged other Southern states to reconsider their stance on Medicaid expansion.

Georgia House Speaker Jon Burns, a Republican, acknowledged the discussions taking place in his state, stating, “Expanding access to care for lower-income working families through a private option—in a fiscally responsible way that lowers premiums—is something we will continue to gather facts on in the House.”

In addition to Georgia, state House speakers in Alabama and Mississippi have indicated a new willingness to consider coverage expansion. All three states have experienced a large number of hospital closures, particularly in rural areas.

Medicaid expansion has become “politically safer to consider,” said Frank Knapp, president of South Carolina’s Small Business Chamber of Commerce. In his state, Republican lawmakers are weighing whether to appoint a committee to study expansion.

The shift in political discourse about expanding access to care is viewed as a favorable development by some health policy analysts. It comes as a new crop of conservative leaders grapple with their states’ persistently high rates of poor, uninsured adults.

An additional incentive for states to expand Medicaid is the American Rescue Plan Act of 2021, which offers newly expanded states an additional 5 percentage points in the matching rate for their regular Medicaid population for two years, more than offsetting the cost of expansion during that period.

Despite the progress being made in some Southern states, considerable obstacles remain. Republican Mississippi Governor Tate Reeves still opposes expansion, and several nonexpansion states appear to have little to no momentum.

“A lot of things need to come together in any given state to make things move,” said Robin Rudowitz, director of the Program on Medicaid and the Uninsured at KFF.

Under Medicaid expansion, adults earning up to 138% of the federal poverty level, or about $35,600 for a family of three, qualify for coverage. Expansion has reduced uninsured rates in rural areas, improved access to care for low-income people, and lowered uncompensated care costs for hospitals and clinics, according to KFF analyses of studies from 2014 to 2021. In states that have refused to expand Medicaid, these challenges remain acute.

Alabama’s legislative session began on February 6, 2024. Republican House Speaker Nathaniel Ledbetter has suggested that he’s open to debating options for increased coverage. Expansion could make as many as 174,000 uninsured people in Alabama eligible for coverage, according to KFF data. Ledbetter prefers a public-private partnership model and has looked at Arkansas’ program, which uses federal and state money to pay for commercial insurance plans on the Obamacare marketplace for people who would be eligible for Medicaid under expansion.

In Alabama, lawmakers have introduced a plan that would levy a state tax on gaming revenue and could help fund health insurance coverage for adults with annual incomes up to 138% of the federal poverty level.

Robyn Hyden, executive director of advocacy group Alabama Arise, which supports Medicaid expansion, has seen progress on efforts to increase coverage. “The devil’s going to be in the details,” she said.

Mississippi’s new House speaker, Jason White, a Republican, has stated that he wants to protect hospitals and keep residents from seeking regular care through the emergency room. More than 120,000 uninsured people in Mississippi would become newly eligible for Medicaid under expansion, according to KFF data. White told KFF Health News in a written statement that improving access to healthcare is a priority for business leaders, community officials, and voters.

Burns, the Georgia House speaker, has stated that he’s open to a proposal for an Arkansas-style plan. Republican Governor Brian Kemp has remained silent on the issue, according to spokesperson Carter Chapman.

In South Carolina, Republican lawmakers are considering legislation that would allow them to form a committee to study expansion. State Senator Tom Davis, a Republican from Beaufort who sponsored the bill and previously opposed expanding Medicaid, said he’s not endorsing or opposing Medicaid expansion at this time. “We need to have a debate,” Davis said during a committee meeting in January.

The state legislature would likely have to work with Governor Henry McMaster, a Republican, who, according to spokesperson Brandon Charochak, remains opposed to Medicaid expansion.

North Carolina started enrolling residents under its expansion on December 1, 2023. Patrick Dunnagan, a 38-year-old former outdoor guide from Raleigh, was among the first to enroll. Dunnagan has relied on financial support from his family and has medical debt exceeding $5,000. Medicaid coverage will provide financial security for him.

Dunnagan emphasized that people with chronic health conditions in nonexpansion states are accumulating medical debt and not getting the care they need.

Bills proposed in Texas’ legislature did not receive a vote last year. The state does not allow voter-initiated referendums, which have been a route to expansion in some Republican-led states. An estimated 1.2 million uninsured people would be eligible for coverage if Texas expanded.

Republican lawmakers in Tennessee and Florida have stated that they will not allow Medicaid expansion. In Florida, advocates have launched a petition drive for a ballot initiative, but the earliest it could go to voters is 2026.

In Kansas, Governor Laura Kelly, a Democrat, is once again pressing her state’s Republican-controlled legislature to adopt Medicaid expansion, calling it a “commonsense proposal” that would lower healthcare costs for all consumers and protect rural hospitals. However, the state’s House speaker remains opposed to Medicaid expansion.

Advocates believe it’s only a matter of time before Medicaid expansion happens nationwide as opposition eases and people continue to suffer the consequences of being uninsured. For Dybas in Alabama, the prospect of gaining coverage is enough to make her consider relocating. Perhaps, as in Arkansas, conservatives will adopt models that rely more heavily on commercial insurance.

However, many holdout states in the South—where death rates for heart disease, cancer, and diabetes are mostly worse than in other states—see growing disparities between the health of their citizens and those of neighboring states that have expanded. “There will be a tipping point for all these states,” said Lucy Dagneau, a senior director for the American Cancer Society’s advocacy arm, the Cancer Action Network. The group lobbies state legislatures for expanded insurance coverage.

In conclusion, the reconsideration of Medicaid expansion in Southern states represents a significant shift in the political discourse surrounding healthcare coverage. As public support for expansion grows and powerful sectors of the healthcare industry make their voices heard, it is likely that more states will follow in the footsteps of North Carolina and expand Medicaid coverage. This development could have a profound impact on the lives of millions of uninsured individuals in these states, providing them with much-needed financial security and access to essential healthcare services.